The purpose of this study is to generate an initial substantive theory concerning decision making during health care transitions of older adults in rural North Dakota subacute care settings. Descriptions of the process of decision making will be grounded in the perspectives of older adult residents, their families , and care providers. The specific aims of this study are to: (1) describe the process of decision making used by rural older adults, their families, and care providers during critical points in health care transitions; (2) explicate the characteristics, meaning and outcomes of those decisions; and (3) describe the decision making process within the multiple contexts of health care transitions, subacute care, and rural culture. The grounded theory approach used in this study is based on the methods suggested by Glaser (1978; 1992). The nature of theoretical sampling and the need to sample to saturation of categories precludes an exact sample size. Based on previous studies, sample size will likely include 30 persons including older adult residents, their family members, and care providers. Data generation and analysis will occur in two rural North Dakota subacute care settings through semistructured interviews, observations, and ongoing comparative analysis. Maximum variation sampling will enable saturation of categories in multiple contextual domains.